Important note

This Clinical Policy Bulletin explains how we determine whether certain services or supplies are medically necessary. We made these decisions based on a review of currently available clinical information including:

Clinical outcome studies in the peer-reviewed published medical and dental literature

Regulatory status of the technology

Evidence-based guidelines of public health and health research agencies

Evidence-based guidelines and positions of leading national health professional organizations

Views of physicians and dentists practicing in relevant clinical areas

Other relevant factors

We expressly reserve the right to revise these conclusions as clinical information changes, and welcome further relevant information.

Each benefits plan defines which services are covered, excluded and subject to dollar caps or other limits. Members and their dentists will need to refer to the member's benefits plan to determine if any exclusions or other benefits limitations apply to this service or supply.

The conclusion that a particular service or supply is medically necessary does not guarantee that this service or supply is covered (that is, will be paid for by Aetna) for a particular member. The member's benefits plan determines coverage. Some plans exclude coverage for services or supplies that we consider medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the federal government or CMS for Medicare and Medicaid members.

Policy

Aetna considers the use of any screening aids, diagnostic tools and/or devices that assist in a diagnosis to be an adjunctive technique that is part of the oral evaluation or primary service.

Background

The current clinical standard for the most definitive, accurate and reliable method for diagnosing oral mucosal lesions is the surgical biopsy.

Some devices and instruments are marketed as a way for patients to benefit from improved identification of oral precancerous and early cancerous lesions, and possibly prevent the disease through early intervention. One technique involves chemiluminescence of tissue with a light source. ViziLite® technology (Zila, Inc.) is one such device. Other devices and/or techniques are VELscope® (LED Dental Inc.) and the OraRisk®HPV salivary test (Oral DNA® Labs).

Aetna considers the surgical biopsy the most definitive, accurate and reliable method for diagnosing oral mucosal lesions.* We do not offer a separate benefit for such oral cancer screening or prediagnostic tools.

Similarly, we do not offer a separate benefit for the use of diagnostic tools, devices or techniques used to evaluate oral structures. One example is pulp vitality tests.

*Regarding screening adjuncts, an ADA panel found insufficient evidence to support recommendations for or against the use of light-based technologies compared with conventional operatory lighting alone.1

Code2

D0431 – Adjunctive prediagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or procedures

D0460 – Pulp vitality tests

Revision Dates

Original: November 22, 2005
Updated: November 28, 2007; October 4, 2010; July 11, 2011; September 10, 2012; November 5, 2013; August 25, 2015
Revised: November 20, 2006; October 13, 2008; August 24, 2009; February 28, 2011; July 23, 2014

Property of Aetna. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating health care professionals are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating health care professionals are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

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Clinical Policy Bulletins

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Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. Treating providers are solely responsible for dental advice and treatment of members. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider.

While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. Aetna's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna). Your benefits plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government.

Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change.

Since Dental Clinical Policy Bulletins (DCPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies.

Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met.